This article describes the case histories of three women diagnosed with various blood clotting disorders. The blood clotting disorders had impaired the ability of each of them to carry a baby to full term. The article looks at the similarities and differences between the women in terms of TCM patterns, and Five Element Constitutional Factor (CF). It describes how the medication they were prescribed affected the choice of treatment principles and also their response to acupuncture treatment. It ends with the authorâs reflections on the experience of treating them.

IntroductionMany women who have suffered repeated miscarriages seek out acupuncture treatment. Prior to seeking treatment, some have been diagnosed with one of a variety of blood clotting syndromes, such as Antiphospholipid Syndrome (also known as APS or Hughâs syndrome) and Factor V Leiden. These are auto-immune conditions where the body produces too many blood clotting factors. This may lead to clots and consequent miscarriage. Most women are not aware that they have this condition until they have problems keeping a pregnancy. The term âhabitual miscarriageâ is defined as three or more miscarriages. It is usually only at this stage that investigations into the causes begin. Tests on the auto-immune system are increasingly becoming a part of these investigations. Bio-medical opinion also links blood clotting disorders with many other conditions, ranging from venous and arterial thrombosis to coronary artery disease and stroke (Neuroland.com, 2005).

I have chosen to write about three such women, all of whom have been greatly helped by acupuncture. It struck me that there are some similarities between them, in terms of Constitutional Factor (CF) and TCM diagnosis. As we know, a single western medical diagnosis does not necessarily mean a single TCM diagnosis. However, there are several interesting threads running through these cases.

CASE HISTORY 1BackgroundE, a 43-year-old woman, came with a frozen shoulder. Whilst taking her case history, she said that over the past eight years she had had three miscarriages. The first had been at seven weeks, the second and third at nine weeks. On investigation, she was diagnosed with APS. Her doctor told her that her only chance of being able to carry a baby full term would be to take daily injections of heparin from the moment she finds out she is pregnant. She and her husband had come to the difficult decision that they would not try for children anymore, as they had read about the possible harmful effects of blood-thinners on both the mother and foetus.

E had no other current or past health problems. Her menstrual cycle was regular (26-28 days), the bleeding lasted 5-6 days, she had no pain, no clots and no pre-menstrual tension. However, up until her mid-30s (around the time she began trying for a baby), she had suffered from severely painful periods, accompanied by pre-menstrual vomiting. E had found it somewhat mystifying that the pain and vomiting had stopped literally overnight eight years ago, never to return. She later wondered whether there was a link between this and her developing APS, as if the pathology had somehow gone deeper. As Thorwald Dethlefsen points out in his book The Healing Power of Illness (1990, p. 9) âthat which constantly reveals itself as a series of bodily symptoms is the visible expression of an invisible processâ. In Eâs case, it seems that though the visible expression (painful periods and vomiting) had ceased, the invisible process (APS) had continued.

DiagnosisAfter the initial consultation, I made both a Five Element CF and TCM diagnosis. Eâs colour was green around her eyes. Her voice tone was at odds with her expression of emotion: it was unusually loud except when she was talking about something she felt angry about when it became noticeably quieter. I therefore diagnosed E as a Wood CF. From a TCM perspective, I diagnosed the syndromes of liver-qi and blood stagnation (wiry Wood pulse, slightly purple tongue with thick and purple sublingual veins), and slight kidney-yin deficiency (slightly floating Water pulse and a feeling of heat that increased as the day went on).

TreatmentSix months after E began treatment, her frozen shoulder was long gone and she had decided to continue treatment as she felt it had helped her in other ways too (her sense of well being and energy levels had improved). E came in one day very distressed to have discovered that she was five weeks pregnant. She had a huge sense of dread at the thought of having to go through another miscarriage, which she assumed was a certainty considering the diagnosis of APS.

I spoke to her about the fact that acupuncture can be used to help prevent miscarriage. I made it clear that I did not know whether that would be the case considering she had APS. E did a lot of soul-searching, particularly around her fears of having her first child at the age of 45. We discussed the possibility that the acupuncture could conceivably delay but not prevent a miscarriage â obviously a very undesirable outcome. In the end, she and her husband decided they would like to try and have the baby, and E asked me to treat her to try and prevent a further miscarriage.

My treatment principles were to gently move qi and blood (taking care not to strongly move blood in the lower jiao which would be contraindicated in pregnancy) and nourish kidney-yin.

ResultsOver the course of her treament, Eâs Wood pulse lost much of its wiry quality and her Water pulse began to feel stronger. There was no longer a purple tinge to her tongue. E had blood tests throughout the pregnancy, all of which showed that her blood clotting levels were normal (although at the high end of normal) i.e. that there was no longer any evidence of APS. The danger times for possible miscarriage came and went and E felt very well throughout the pregnancy.

Nine months later, at the age of 45, E gave birth to a healthy baby boy.

DiscussionE had not taken any blood-thinning medication during her first three pregnancies and had miscarried each time. She also decided not to take blood thinners during this pregnancy, which was unplanned. She and her husband had reconciled themselves to the fact that they would not be birth parents. They felt strongly that, even though they had desperately wanted to have children, the risks to E of going through pregnancy and childbirth with APS and not taking heparin, were too high. The last blood test confirming APS was approximately a year before E began acupuncture treatment. She had had six months of weekly, fortnightly and then three-weekly treatments before she became pregnant.

E and I will never know how far the acupuncture treatment contributed to her being able to carry a baby full-term. It is obviously quite a feat for any 45-year-old, let alone one who has been told she will never have children unless she has daily injections of heparin throughout pregnancy. By the time E became pregnant, her Wood pulse was consistently less wiry, her kidney pulse felt stronger and her tongue had lost its purple tinge. E herself felt very strongly that the acupuncture treatment had been a âkey factorâ in her being able to reach full-term.

E is a psychotherapist and was very interested in exploring the connection between suppressed emotions and disease. When I asked her what she thought the emotional component of her having APS was, she answered, âWell, itâs obvious isnât it, itâs the angry womanâs diseaseâ. During the initial consultation, E had said that until her mid-thirties she felt she behaved âlike a stroppy teenagerâ â always flying off the handle and feeling constantly irritated. It is impossible to know when her APS first began but I wondered whether suppressing her âangry behaviourâ had contributed towards its development.

CASE HISTORY 2BackgroundS, a 36-year-old woman, came to see me because she was having problems conceiving and keeping her pregnancies. She had become pregnant after a year of trying to conceive but miscarried at eight weeks. She then fell pregnant again three months later and again miscarried at eight weeks. She went to see a fertility expert who diagnosed that her thrombin levels were too high (which may lead to excess blood clotting) and told her that if/when she became pregnant again she should take aspirin daily throughout the pregnancy.

Her only other complaint was that she had suffered for the last ten years from headaches which generally lasted two or three days and came either just before or at the beginning of her period. She described the headaches as feeling like âa clamp around her headâ. She had also had headaches of a similar nature permanently during both her short pregnancies.

Her periods lasted five days and were neither particularly heavy nor light. Her cycle was generally regular. If anything, it was sometimes on the short side (26-28 days). Her periods were virtually painless. As well as the headaches, she also suffered from pre-menstrual syndrome, breast-distension, constipation and bloating.

DiagnosisI also diagnosed S as a Wood CF. She had a noticeable green hue around the sides of her eyes and around her mouth. She had achieved a great deal in her career in the City, a very competitive and male-dominated world, yet with me she was unusually lacking in assertion. Through questioning, it became apparent that she had a history of being overly-compliant in her personal relationships and friendships. She arrived late for treatment one day explaining that when she went to get in her car, she found that the wing mirror had been pulled off and two of the tyres slashed. She expressed absolutely no anger at this, yet when I took her pulses, her Wood pulse was extremely wiry. Her odour was rancid.

In terms of TCM patterns, I diagnosed liver-blood deficiency (pale and thin tongue, choppy Wood pulse, blurred vision, pins and needles, headaches) and the beginnings of liver-yin deficiency (dry, itchy eyes, feeling of heat in the afternoon). These two deficient syndromes had led to some liver-qi stagnation (Wood pulse which was sometimes wiry, pre-menstrual headaches and some pre-menstrual tension).

TreatmentMy treatment principles were to nourish liver-blood and yin during the first three phases of Sâs cycle and move qi during the fourth phase.

S became pregnant again after a month of having acupuncture treatment. She began taking aspirin immediately as had been advised by her doctor and continued to do so until week 36.

When S told me she was pregnant, I adapted my treatment principles and focused solely on nourishing qi, blood and yin. Gascoigne (2001, p.401) asserts that aspirin has a dispersing action. Hence, because it moves qi and blood, I stopped doing this with acupuncture in case the combination of the two was too strong and led to miscarriage. Gascoigne (April, 2005) further states that, because of its heating and moving actions, aspirin also depletes qi, yin and blood. As I saw Sâs condition as being largely deficient in nature, I therefore felt it necessary to support her qi, blood and yin to help counteract the possible harmful effects of the aspirin.

She continued having weekly sessions of acupuncture for the first three months of her pregnancy and then monthly treatments during the second and third trimesters. She had no headaches throughout her pregnancy.

S gave birth to a healthy, 10-lb baby boy after nine months.

DiscussionThe syndrome most likely to be contributing to Sâs difficulty in keeping a pregnancy was liver-blood deficiency. So why had this syndrome occurred in S in the first place? I suspected that part of the reason was that, since school, S had expended a huge amount of energy pushing herself to continually grow and push forward in terms of her academic, and later, her professional work. Rather as a fast growing plant saps all the nourishment from the soil in which it lies in order to grow ever taller, too much of Sâs Wood energy had been consumed in achieving all she had in her career and there was little left to nourish a foetus in her womb. After all, most of the blood stored in the uterus comes from the liver (Maciocia 1998, p.13).

I suspected that Sâs blood had also become deficient due to her tendency to internalise her anger. In an article entitled The Nan Jing, Difficulty 16 and Liver Blood deficiency, Williams (2004, p. 16) describes how an already blood-deficient person lacks the force to fully express their anger, which is then internalised and depletes the blood further. A vicious circle is then created. S rarely expressed any anger, yet she had a considerable amount of anger inside her.

CASE HISTORY 3BackgroundL was a 46-year-old woman. She came to see me because, during the last four years, she had suffered from frequent attacks of severe dizziness. She also temporarily lost feeling in her left hand and the left side of her face. Her vision would become blurred with blind spots and she would feel what she described as a âwhooshâ going up to her head. Afterwards she would be left with an overwhelming desire to sleep and a feeling of heaviness. A consultant had diagnosed her as having repeated Transient Ischaemic Attacks (TIA).

Previously, while undergoing five rounds of IVF, L had been diagnosed with a blood clotting syndrome called Factor V Leiden. The medical profession believed this was the cause of her TIAs. Since this diagnosis in 2000, she had been prescribed daily aspirin. She was also told to take heparin if she was ever pregnant again or when going on long-haul flights. She had conceived three times, twice losing the baby late in pregnancy. On the third occasion, she tragically gave birth at 28 weeks and the baby had died when she was four months old.

Lâs menstrual cycle had always been regular. She had very light bleeding that lasted for three days, no pain or clots, and very little pre-menstrual tension.

DiagnosisI diagnosed L as a Fire CF. During the initial consultation, she oscillated constantly between an overwhelming state of melancholy one minute and laughter (which was often inappropriate) the next. She craved warmth and intimacy and felt very easily rejected by her husband and friends. She would describe becoming upset if even strangers, such as shop keepers, did not greet her warmly. Her odour was scorched.

Her predominant syndromes were blood deficiency of the liver, spleen and heart (very pale tongue, scanty periods, palpitations, anxiety, light and dream-disturbed sleep and a choppy pulse). I diagnosed her TIAs as being due to a combination of liver-yang rising (she described them as a âwhooshâ up to her head) and phlegm (manifesting in acute dizziness during the attacks and a strong desire to sleep afterwards). She also had spleen-qi deficiency and a considerable amount of damp. This showed on the tongue, which was very swollen with teethmarks, and in her constant feeling of heaviness and lethargy.

TreatmentI initially focused on clearing damp and phlegm and subduing liver-yang. I then began to nourish liver and heart-blood and tonify spleen-qi. I tonified Lâs pericardium and triple burner every treatment in order to help strengthen her CF.

ResultsL has been having acupuncture for almost a year and, during this time, has only had two TIAs. Interestingly, one occurred shortly after I began treating her on the anniversary of her babyâs birth, and the other four months later on the anniversary of her babyâs death. Prior to coming for treatment, she had had TIAs every two or three months. L also felt that she now took less time to recover from them than she used to. Her depression and lethargy have lifted, although she still finds her babyâs birthdays and the anniversaries of her death difficult. She feels her moods are less volatile and she has much more energy.

Discussion Although I diagnosed L as a Fire CF, I felt that her Wood was also heavily implicated in her ongoing state of depression. Kubler-Ross (1970) talks about anger (a yang emotion) being a necessary phase of grief. L was completely stuck in a yin response to her babyâs death. Her grief and pain six years on from the event, completely dominated her thoughts and feelings. She still cried about it every day, felt sorely lacking in motivation and often struggled to get out of bed. I saw her TIAs as a rising up of the anger over her babyâs death, manifesting physically as it had no emotional outlet.

ConclusionWhich TCM syndromes seem to be present in cases of blood clotting disorders? As may be expected, pathologies of blood were present in all three women. In patient E, liver-blood stagnation was predominant and the primary treatment principle was to move liver-blood. It was predominantly a full condition. In patients S and L, the primary blood pathology was one of deficiency and therefore the treatment principle was to tonify blood. These were predominantly empty conditions. One of the most common causes of stagnation of blood is blood deficiency. As always, whatever the western diagnosis given, treatment must be according to the principles of Chinese medicine.

TCM recognises both blood deficiency and stagnation as causes of miscarriage (West, 2001, p. 124). When miscarriage occurs during the first trimester it is often attributed to kidney deficiency and during the second trimester to spleen deficiency (Maciocia 1998, p. 557). However, in the cases described above, liver-blood is at the core of the pathology.

What is the significance of the CF diagnosis in each of these cases? I diagnosed E and S as Wood CFs. Although L is a Fire CF, I thought that an imbalance in the Wood element was the cause of her TIAs. Therefore, in each of the women an imbalance in the Wood element lay at the heart of their condition. Wood is the first element of the sheng or âgeneratingâ cycle (Maciocia, 1989, p.19). The power of Wood is birth (Hicks, et al 2004, p. 59). It is largely the Wood element which determines our ability to be creative, one of the ultimate expressions of creativity being, literally, to âcreateâ another being. Jarrett (2000, p. 237) explains that Wood has a different rhythmic quality to the other four elements. It âensures that life never proceeds in a circle but always in an upward evolutionary spiralâ. Therefore Wood is key to the process of conceiving and bringing a new being into the world.

How did the patientsâ medication influence their acupuncture treatment? Gascoigne (2005) believes that aspirin is a warm, acrid and dispersing drug that has the following energetic effects:â¢ moves qi and bloodâ¢ depletes spleen and lung qiâ¢ depletes blood and yin (because of its heating and moving actions)â¢ creates stomach-heat (a common side-effect of aspirin is bleeding in the stomach).

Gascoigne believes that heparin also heats and moves the blood and that, after long-term use, it leads to blood deficiency.

Taking the above into account, my three patients would have all responded to blood-thinning medication in different ways. Although E chose not to take aspirin or heparin during her pregnancy, she perhaps would have been able to tolerate it the best as the state of her qi and blood was stronger than that of S and L. My decision to base her treatment around moving qi and blood was taken on the basis that her condition was more full than empty. Considering the fact she was not on medication to move blood, using acupuncture to achieve this seemed the most appropriate option.

S had decided to take aspirin during her pregnancy, a decision which somewhat worried me because I did not feel that the state of her blood could withstand anything that would further deplete it. I therefore based my treatment around tonifying her blood in the hope that this would support the ben (i.e. blood deficiency) while the aspirin treated the biao (blood stagnation).

L had already been taking daily aspirin for four years before she came to me for treatment and I wondered how much this contributed to her fairly severe qi and blood deficiency. She and her husband had, with great sadness, decided not to continue trying for a baby and the reason for her continuing to take aspirin was because her consultant had worried that her Factor V Leiden syndrome predisposed her to DVTs, stroke and heart problems. As is so common with our patients, their long-term medication treats the biao, but weakens the ben. Treatment was therefore focused on strengthening Lâs underlying condition, i.e. tonifying her qi and blood.

ReflectionsIt feels both a huge responsibility and privilege to work with women who are trying to conceive or are pregnant. My experience of treating these three women highlighted several things for me.

Firstly, treating S and L highlighted for me the importance of taking into account the energetic effects of our patientsâ medication. My treatment principles would have been different, especially in the case of S, if she had not been taking aspirin throughout her pregnancy.

Secondly, it reminded me of the importance of always treating the patterns according to the symptoms and signs of that person. It goes somewhat against the grain to move qi and blood during the first three months of pregnancy, as I did in the case of E. I felt apprehensive about using treatment principles that should be applied with extreme caution during pregnancy. There was also a part of me that wanted to âplay safeâ and simply tonify these three womenâs kidney qi, kidney deficiency being the generally accepted cause of most first trimester miscarriages. As a practitioner, it is easier to endure the sense of regret when oneâs patients do not respond to treatment if we feel we have done âthe right thingâ according to the textbooks. But to go against the grain, especially when treating pregnant women, and then to âget it wrongâ would be more difficult to bear.

Thirdly, when I began treating S and L, several months after treating E, there was a part of me that expected to find they had similar patterns. It was hard to avoid making the rather simplistic correspondence between the western medical term of âblood clottingâ and the Chinese medicine term of âblood stagnationâ. However, as we are reminded countless times every day when we practise, things are rarely that simple. S and L both had primarily deficient conditions and the treatment that they required was very different to that which I had given E.

As Lyttleton points out: âThe only proof we have to date that TCM treatment for recurrent miscarriage offers some valid outcome is its performance in the living Peopleâs Laboratory of China, where it has been employed for thousands of years and is still in use todayâ (2004, p. 304).

There is no way of knowing whether the autoimmune conditions described in the cases above have always been so prevalent. They may only now, with the advancement of medical science, be detectable or they may be modern phenomena. My hope is that, as practitioners, we will not be too daunted or demoralised by ever more complex western diagnoses that our patients present and that, while taking these into account, we continue to practise our astonishingly powerful art based on what we find in front of us.

(A full Bibliography for this article is printed in the hard copy of The European Journal of Oriental Medicine Vol. 5 No. 3; 2006.)

Rebecca AvernRebecca Avern trained as an acupuncturist at the College of Integrated Chinese Medicine, graduating in 2001. She is now a member of the college's teaching staff, as well as head of Library and Learning Resources. She worked with Giovanni Maciocia for four years, assiting him in the writing of Diagnosis in Chinese Medicine. She practises in Berkhamsted, Hertfordshire.